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HomeMy WebLinkAboutBLDG-24-204 4 12LS 1-1 v( L- (\ ' ` I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t, ...W CITY IvtA D ' • J�lei -2 _Z . JGBSITE ADD L. 12T �`a /i" ' _3'' OWNER'S NAM J GOWNER ADDRESS TEL ,4( , TYPE OR Per OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ElRESIrEI' La CLEARLY NEW:qY RENOVATION:❑ REPLACEMENT:1] au LhaG DEPARTMENT ' it EN' fi III APPLIANCES 7 FLOORS-r SW 1 2 3 4 s s 7 8 9 10 11 12 L 3 1" BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER -DRYER —_= FIREPLACE —1 FRYGLATOR - - FURNACE GENERATOR GRILLE _ -- INFRARED HEATER LABORATORY COCKS --______— MAKEUP AIR UNIT - - OVEN POOL HEATER -- • ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER VENTED ROOM HEATER . ---I, WATER HEATER y y� _ OTHER PQ1( i�I1r�/-�A,-6a� :1,--- ` INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent meets the requirements of MGL Ch.142 YES }0❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURAI'lCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER,OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑ �. I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a urate to the best of my knowledge `- and that all plumbing work and Installations performed under the �' Massachusetts State Plumbing Code and Chapter 142 of the General it Issu laws ed for this application will be in compliance th all Pertinent provision of the Qj PLUMBER-r, qME / LICENSE# �G/� SIGNATURE MP GF J �( JGF LPGI❑ CORPORATION 0# �j PARTNERSHIP # LLC 0# COMPANY IJ �[/'a�,1,, rL�J-1 ', / ADDRESS -c/��n/ /C�GAN K� CITY n—/L!V`V v`-4- SSTATE gt h ZIP O L-i)-7 3 TEL 6O 3 3 k1 FAX CELL EMAIL OI I�O d17")a f 00493 i i VI 0 I 0 1 hM 1 L) 1 W 1 MM 1 .7 I 1 i 1 1 0 !n I w "'O 1 co I r 0 0. 0 I 2 a 1 r4 a w cn �a 0 ab Q Uri. 1 U3 Il l F- tL !I) I H Z. G 1 Gad T iI c 0 77C75 ' r) y q, I/ /6) � � �b(10 mot)* 0 Z� 7-3 sEP 3 0 2�24 �� g j EPRTMEN A 6Y.�I p‘ts/47 doofib et/n0 7 (,5?-67r10 / /) 1/6 XIV 4-4//1/1 7 n -IV (R-7 e-4 s(r1647e(Cil 363 0 ze.7 41107/0 (3 O2- 1 0;i/ gOt r 01 1)��Y) ©(1 VI phorvi Q, v" 1 /t/A 9 fr /� (//7 Gi/teAti fly 7-8 p, u 112 S) (, -040 , , , ,/i, 07 4 -Jild -/- ,yati,(1 7(,) ci ---.)/ uf -)/),(/ 0 n , , 71 ,7,y a7 Qt � a ,l- m.'Tn,m � 9) ,2 V i/f f, ,151g ,o, ? ..vv ,§,,,ovl 9 ,,L (:- A ---'-/-- )/1 I 'm J tV p r;r! idfd 0/--- c70,011 -- 1-4 ----------T-°------7/ °'A-44()b i l*d"'- ' lift.p -i 4_t1 71- 1v0/07 ,i_oof 440 .il , / -2, 3Loyy /-y_e7koo 7L /2-pyz- .1,202 -7,/ 5';(1.100 . --?/.1/ dr ' 1 A/Ph) ir)), - ( V9 A IA!:5) ‘)/- el 1'() - � Va ill , gVYl -zffT1,,,,00 �"�'juNw/ /Y'� u ,,s y,5 , 6 y(k. i j,,,h, p "7 is '6' 'ts rR!./- 24d Jsiwg r /bnz -39/49(1V 6 ,,f,7 ,(0, ,z,,, („ i--21..031 , / 7 ° v �Y /y�oowl,"oLf' 3u,oSf r'� p � ���u1o9 , p oJp